Contingency Management (CM) with Adolescents & Their Families

Ashli J. Sheidow, Ph.D.Family Services Research CenterDepartment of Psychiatry & Behavioral SciencesMedical University of South Carolina

The presenter’s research has been supported by National Institute on Drug Abuse awards

R01DA017487 (PI: Henggeler) & K23DA015658 (PI: Sheidow)

Background for Today’s Training

Strong empirical evidence for the use of CM in adolescents e.g., Azrin & colleagues, 1996, 1994, 2001

Cognitive Behavioral Strategies Identify triggers of drug use Manage triggers Develop drug refusal skills

Behavioral Strategies Monitored drug use Incentivize abstinence

Point-and-Level System

Incentives for abstinence and disincentives for use Clean tests (no drug use) = rewarded with points Dirty tests (drug use) = no or loss of points + loss of

valued privilege Other desired behaviorsa = bonus points Points can be exchanged for various rewardsb

aOther desired behaviors Examples: aggression, arguing, school attendance,

homework completion, household rule breaking, chore completion

bEffective Reward Menu Effective incentives & disincentives Associated points determined strategically Steps for tracking points and incentives

Start with the Carrot

Step 1: Identifying Motivational Items Potential rewards that are motivating for

THIS youth Items Activities Privileges Do not necessarily have to cost money Rewards list:

Generated by the youth Edited by caregiver & therapist

Procedure: Provide examples Generate list Rank order

List of Potential Rewards

Type of Reward What I Get What I Want What Parent Provides

Transportation(most valued privilege)

Ride to recreation

center once a week

Borrow the car on Saturday

I usually give him rides 3-4 times a week to places.

Driving Practice None DailyI haven’t let him try

practicing even though he has a practice permit.

Clothing

One outfit at the start of the school

year

At least one new outfit a

month

I buy him new clothes or shoes once a month or

so.

Favorite Dessert/Meal

Never Every day

3-4 times per week I usually fix him spaghetti,

fried fish, pound cake, and chocolate chip

cookies.

Meals

She cooks dinner,

sometimes makes

breakfast and packs my

lunch

Nothing

I cook everyday. I make him breakfast and pack

his lunch or give him lunch money.

Lunch/Dinner Out

1-2 times per month

1-2 times per month

We all go out 1-2 times per month.

List of Potential Rewards (p.2)

Type of Reward What I Get What I Want What Parent Provides

Laundry Once a week Once a week

Once a week and sometimes I will wash something he wants to

wear. I also iron his clothes when he asks.

TV Use Daily Daily

Daily. I also bought him X-Box which he plays

every day. I buy him at least one game a month.

Curfew

7:30 during the week and

9:00 on weekends

9:00 during the week and midnight on weekends

I am following probation orders.

Have a Friend Visit

Every day NothingHis friends are always

here.

Go To a Friend’s House

About once a week

2-3 times per week

I don’t like all his friends so I don’t allow him to go

to their homes.

Invite Friend Sleep-Over

Never1-2 times per

monthI have not allowed this.

Non-Drug/Alcohol Party/Get-Together

NeverAt least for my

birthdayI have not done this.

List of Potential Rewards (p.3)

Type of Reward What I Get What I Want What Parent Provides

Own Phone A cell phoneHas a cell

phoneWe gave him a cell

phone.

Upgrade PhoneLow-end cell

phoneRazor cell

phoneBasic phone.

1-on-1 Time with Dad

NeverHang out 1-2

times per month

He sometimes gets to watch sports with his dad

1 time a month.

Own RoomShare room with little brother

Move into the office

We use the office, but could maybe move

computer to kitchen.

Stuff for RoomNothing –

looks like a kids room

Posters, bedspread, lamp, rug,

paint

We could provide some of those.

Trips With Family/Friends

No

Wants to go to local

amusement park

We have not done this.

Movie Theater with Family/Friends

No1-2 times per

monthWe could sometimes

afford.

Own Car (Registration, Insurance, Payments)

No Wants a car We cannot afford.

List of Potential Rewards (p.4)

Type of Reward What I Get What I Want What Parent Provides

Computer NoWants a

computerWe cannot afford.

Weights, Sports Equipment

Some weightsMore

equipmentHe wants a

bench/weights.

Music Player/i-Pod

DailyHave stereo –

daily use; wants i-Pod

He uses stereo daily. May get i-Pod.

Play Football Weekly in fallWant to stay

on teamHe plays, I try and

support.

Pet/Pet Supplies None A pit bull We cannot afford.

Other Item: Jewelry

Ring last fallBracelets,

rings, necklaceI bought him ring for his

birthday.

Other Item:Good report to my probation

officerOnce a month

I tell the truth – bad reports.

Other Item:

Reward Menu

Step 2: Edit the List of Potential Rewards Caregiver determines final list of rewards Each reward must meet 4 criteria:

It does not contribute to irresponsible behavior.

It is non-essential. Caregiver is willing & able to withhold the

privilege if it’s not earned. It’s reasonable given the context in which the

youth & caregiver live.

Monetizing Rewards

Step 3: Assign Points to Rewards Less valuable rewards = fewer points More valuable rewards = more points Rewards able to be given daily = fewer

points Weekly/Monthly Rewards = more points Points can be equated to a $ value Review rewards to see if any

monetary rewards should have an added "tax"

Make It Personal

Step 4: Personalize the Contract Contract clearly outlines what the youth can

earn in return for doing good behaviors Points awarded and deducted for the youth’s

behaviors Possibly use “Base Points” Assign points to each desired behavior

Points can be earned Points can be lost Bonus points can be awarded

Level System: Escalating Reinforcers Moving up levels and down levels: Rapid Reset

Rewards and the rewards’ associated points Disincentives and associated points

Take It to the Bank

Step 5: Track points Checkbook System

Graphing System Run “what ifs” on the plan

It’s Showtime!

Step 6: Sign the Contract

Step 7: Implement the Contract

Step 8: Revise the Contract

The Proof is in the Pudding

Drug screens ensure we are accurate We usually can’t observe the youth’s drug use Screens ensure

i. good behavior (abstinence) is always rewarded ii. while bad behavior (drug use) is always consequented

Drug screens ensure contingencies are provided consistently

Use can receive a consequence right away Abstinence can be rewarded right away

Drug screens alleviate caregivers having to make judgments of youth’s truthfulness

Note on Adulterants: Products are readily available on the market and are constantly being produced and modified to mask the presence of drugs in urine. To find out more about these agents, consult the National Institute on Drug Abuse website (http://www.nida.nih.gov) or a local laboratory.

Teaching Caregivers to Test

Before collecting the sample: 1. Take everything out of the bathroom that the

youth could potentially use to alter the urine specimen (cleaning solutions, any containers, medications, etc).

2. Place dye in the toilet bowl and in the top of the tank.

3. Tape water faucets so that they cannot be turned on without breaking the tape.

4. Place youth’s name and date on the cup. 5. Ask the youth to remove jacket or bulky

clothes that can conceal objects, as well as turn pockets inside-out.

6. Put on disposable gloves.

Teaching Caregivers to Test

Obtaining the urine specimen: 1. Ask youth to provide the specimen with

appropriate supervision (stand at the doorway facing out – close enough to be able to hear any suspicious activity).

2. When youth has provided the specimen, have him or her replace the cap.

3. Take the specimen from youth and place on a flat surface; make sure the cap is on tightly.

4. Read the temperature strip on the cup and ensure that the urine is between 90 and 100 degrees.

Drug Testing Schedule

Determine frequency of drug testing Individualize Regular & Random High risk times Indicated Sufficiently frequent Average detection times

See Table on Next Slide

Average Detection Times

3Tested in most 3-panel urine drug screens; 6Tested in most 6-panel urine drug screens;Adapted from American Association for Clinical Chemistry (1988).

Drug Urine Detection Time

Amphetamines6 2-5 days

Barbituates (Short-Acting) 2 days

Barbituates (Long-Acting) 3-4 weeks

Benzodiazepines6 Varies by type of drug, many are 7-10 days

Cannabinoids (THC, Marijuana)3, 6

1x only = 5-8 days; 2-4x/month = 11-18 days;

2-4x/week = 23-35 days; 5-6x/ week = 30+ days; Daily=30+ days

Clenbuterol (illegal weight loss drug)

4-6 days

Cocaine3, 6 1-4 days

Codeine 5-7 days

Euphorics (Ecstasy, Shrooms) 5-7 days

Ketamine (Special K) 5-7 days

LSD - ACID 7-10 days

Methamphetamines3, 6 5-7 days

Nicotine (Cigarettes) 4-10 days

Opiates6 5-7 days

Phencyclidine (PCP) 2-4 days

Phenobarbital 10-20 days

Propoxyphene 6 hours to 2 days

Steroids (anabolic oral) 14-28 days

Steroids (anabolic injection) 1-3 months

Additional Resources

General Resource: www.nida.nih.gov Integrated Instant Test Cups and Alcohol

Breath Scans: ushealthtests.com www.btnx.com www.uritoxmedicaltesting.com www.floridadrugscreening.com www.varianinc.com www.drugtestsystems.com

Parenting Your Out-of-Control Teenager: 7 Steps to Reestablish Authority and Reclaim Love by Scott P. Sells (esp. Chapter 2: Writing an Ironclad Contract)

Common Dilemmas Caregiver: I don’t know if I agree with giving him rewards. He has caused so many

problems in the past he should just do what he needs to do. Therapist: That’s a common response I hear from parents who have been hurt by their teens’ behavior.

One way to look at it is this: the contract program, although it will be critical that you are involved, will actually take some emotional pressure off of you. It will be up to him if he earns the reward, so you will not have to be the bad guy—it is his decision. In this way, you’re teaching him that good behavior is rewarded—he needs to stay clean and follow your rules to be rewarded—and there are immediate consequences for negative behavior—using drugs and not following your rules. So, you are preparing him for adulthood, where he will learn to take responsibility for himself.

Caregiver: So you’re telling me that you want me to pay off my son for staying off of drugs when he just shouldn't use in the first place?

Therapist: That’s an excellent question and is a concern many parents have. Getting off drugs is a very difficult thing to do for adolescents because the drug use makes them feel good. So in order to overcome this "good feeling" we have to develop an incentive that’s more rewarding than the good feelings they get from the drugs. This way, when your son is confronted with the option to use drugs, he’ll choose to stay clean to earn the incentive, instead of using. As you will see, we won’t reward him forever, but we need to start rewarding him for being clean so that he can get himself off of the drugs. Also, don't think of it as paying him off because he must work very hard to earn these incentives. So whether or not he earns them depends on if he is willing to put in the hard work.

Caregiver: Well, shouldn’t he just stay off drugs so that he’ll graduate school, not go to prison, and that sort of thing?

Therapist: Great! You’re bringing up the most common concerns right up front! We’ve found adolescents don’t seem to be very affected by consequences that are farther into the future. Perhaps it would help to think of it like this: imagine if my boss told me I need to do my work, but that I won’t get paid ‘til next year. Perhaps I’d stay motivated for a few days or weeks, but I’m fairly certain I’d quit doing my work and start goofing off & having fun instead!

Caregiver: Why do we have to write this all down and have a “contract”? Therapist: By having a contract, we will all be on the same page. That is, everyone will be aware of the

expectations for Jake and for Mom. We will all know that drug use (and other problem behaviors) will be regularly assessed and when and how incentives will be provided. By establishing clear expectations we minimize the chances of confusion. You can think of it like you would think of a contract for a job—the contract lists the expectations for you (such as showing up on time and working a certain number of hours), as well as for the business (such as paying you a certain amount, keeping you safe while you’re at work, and so forth).

Ashli J. Sheidow, Ph.D.Family Services Research CenterDepartment of Psychiatry & Behavioral SciencesMedical University of South Carolinaemail: sheidoaj@musc.edu

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